ABSTRACT
Multiple Choice (choose the one best answer) 1. A 40-year-old migrant worker from Mexico presents to
the emergency department with complaints of epigastric pain, melena, and nausea. Esophagogastroduodenoscopy shows a 2-cm duodenal ulcer, and antral biopsy specimens are positive for Helicobacter pylori. The primary reason to eradicate H. pylori infection in this patient is to: a. Reduce the risk of gastric cancer b. Heal the duodenal ulcer c. Heal the duodenal ulcer and decrease the risk of recurrent
ulcer d. Prevent an inevitable MALToma e. Prevent transmission to his wife
2. On further questioning, the patient in question 1 recalls having a similar episode of gastrointestinal tract hemorrhage 5 years previously. Upon discharge, you tell the patient and his family that: a. A 14-day course of medication will solve the problem b. In addition to 14 days of triple therapy, he will need 6
weeks more of antiulcer medication c. His risk of reinfection from other infected family mem-
bers who are positive for H. pylori is approximately 15%-20%
d. In addition to proper medical therapy to eradicate H. pylori infection and to heal the ulcer, the patient will need a test to confirm that infection has been eradicated
e. You now are concerned about a possible ZollingerEllison syndrome
3. An 82-year-old man who is active and in excellent health recently injured his back while riding a lawnmower. He began a course of ibuprofen therapy in addition to his usual 81 mg of aspirin. He complains of fatigue, shortness of breath, dizziness, and a pale appearance. He states that he has no abdominal pain, nausea, vomiting, or diarrhea. His stool is dark in color. However, he mentions that he recently took Pepto-Bismol for his “flulike symptoms.” The patient is at increased risk for gastric ulcer complications because of: a. Age b. Recent gastrointestinal flu c. History of “stomachache” in high school d. His overall health status e. Pepto-Bismol
4. A 29-year-old woman complains of recurrent peptic ulcer disease. She has been hospitalized three times for bleeding duodenal ulcers. Currently, she is taking a proton pump inhibitor twice a day and complains of headache, diarrhea, and gastroesophageal reflux symptoms. The best initial test to diagnose her condition would be: a. Serum parathyroid hormone b. Serum prolactin c. Serum gastrin d. 24-hour 5-HIAA (5-hydroxyindoleacetic acid) e. Giardia stool antigen
5. The patient is found to have elevated levels of gastrin, parathyroid hormone, and prolactin. This clinical condition is known as:
a. Multiple endocrine neoplasia (MEN) type I b. MEN type II c. Zollinger-Ellison syndrome d. Carcinoid syndrome e. Mastocytosis
6. A 65-year-old woman with a past history of hypothyroidism who is receiving replacement therapy is referred to you for evaluation of gastrointestinal tract upset and a serum gastrin level of 1,200 pg/mL. She has been told she has Zollinger-Ellison syndrome. The initial test of choice to evaluate this patient should be: a. Repeat serum gastrin level b. Serum calcium level c. Gastric analysis d. Parathyroid hormone level e. Thyroid-stimulating hormone level
7. A patient undergoes esophagogastroduodenoscopy and, at the time of gastric analysis, is noted to have multiple small nodules (2-3 mm) (Figure). Biopsy specimens from these nodules show carcinoid tumor. You recommend: a. Subtotal gastrectomy b. Somatostatin therapy c. Proton pump inhibitor therapy to suppress gastrin level d. Endoscopic resection of the nodules e. Computed tomography of the abdomen to rule out
metastatic disease
8. A 24-year-old alcoholic with chronic hepatitis C infection is admitted with hematemesis and melena. The endoscopic findings noted at esophagogastroduodenoscopy are shown (Figure). The diagnosis of the etiologic cause for his bleeding is: a. Ectopic varices b. Gastric antral vascular ectasia c. Portal hypertensive gastropathy d. Nonsteroidal anti-inflammatory drug (NSAID) gas-
tropathy e. Alcoholic gastritis
9. A 75-year-old man presents with belching, vague abdominal pain, and a remote history of Helicobacter pylori infection treated 10 years earlier. The patient’s father died of gastric cancer. The esophagogastroduodenoscopic findings (Figure) are of concern because of an association with: a. Achlorhydria b. Vitamin B12 deficiency c. Risk for gastrointestinal tract hemorrhage d. Risk for dysplasia e. Nonulcer dyspepsia
Question 7
Question 8
Question 9
10. loose stool, and depression. He has been told he has irritable bowel syndrome. You order esophagogastroduodenoscopy, and a biopsy specimen from the endoscopic finding (Figure) shows an infiltration of lymphocytes. You recommend the following: a. Helicobacter pylori serologic study b. Serum tissue transglutaminase level c. Computed tomography with attention to the lymphatic
system d. Serologic study for Whipple’s disease e. Discontinue nonsteroidal anti-inflammatory drug therapy
11. A 72-year-old man presents with dysphagia, 25-lb weight loss, early satiety, aversion to meat, and melena. He has a great fear of gastric cancer because his father died of it at age 59. The esophagogastroduodenoscopic findings are shown in the Figure. You recommend to the patient: a. Imatinib mesylate to shrink the tumor b. Radiotherapy and chemotherapy c. Eradication of Helicobacter pylori to reverse the condition d. Surgical resection e. YAG laser therapy
12. The patient in question 11 states that he fears his sibiling and children are at risk for gastric cancer, and he asks if there is any way to prevent this disease from developing in them. You suggest: a. Genetic counseling for possible family cancer syndrome b. Folate, vitamin B12, vitamin C, vitamin A, and vitamin
E supplementation c. Screening for Helicobacter pylori infection d. Yearly endoscopic surveillance with biopsy e. No need for concern
13. The most frequent gastric tumor caused by Helicobacter pylori is: a. MALToma b. Gastrointestinal stromal tumor c. Adenocarcinoma d. Carcinoid tumor e. T-cell lymphoma
14. A 62-year-old woman with a past history of stage I adenocarcinoma of the breast presents with painless hematemesis and melena. Emergent esophagogastroduodenoscopy (EGD) was performed. The lesion shown in the Figure is most likely a: a. Gastrointestinal stromal tumor b. Leiomyoma c. Leiomysarcoma
Question 10
Question 11
Question 14
e. Kaposi’s sarcoma
15. would be: a. Imatinib mesylate b. Endoscopic resection c. Surgical resection d. Local radiation e. Systemic chemotherapy
16. Which of the following is a false statement about metoclopramide (Reglan)? a. Metoclopramide is FDA-approved for the treatment of
gastroesophageal reflux disease b. Metoclopramide is FDA-approved for the treatment of
diabetic gastroparesis c. Metoclopramide is FDA-approved for the treatment of
idiopathic gastroparesis d. Metoclopramide is pregnancy category B e. The dosing of metoclopramide is reduced in renal
failure
17. Which of the following statements about upper gastrointestinal tract symptoms is false? a. Postprandial fullness severe enough to change usual
activities is associated with delayed gastric emptying b. Early satiety is associated with impaired gastric
accommodation c. A therapeutic response to a trial of metoclopramide is
an effective way to diagnose gastroparesis d. Symptom patterns alone are unable to distinguish
between functional dyspepsia and organic disease e. Postprandial fullness can be secondary to partial small-
bowel obstruction
18. Which of the following statements about normal gastric function is true? a. In the postprandial period, the largest size food particle
that can pass through the pylorus is 10 mm b. In the postprandial period, the largest size food particle
that can pass through the pylorus is 6 mm c. In the postprandial period, the largest size food particle
that can pass through the pylorus is 2 mm d. In the postprandial period, the largest size food particle
that can pass through the pylorus is 1 mm e. The presence of phase III of the migrating motor complex
(MMC) in the postprandial period ensures that the enteric nerves are working well
19. Gastroduodenal manometry (GDM) is a useful clinical test in which of the situations below? a. In the evaluation of a patient with scleroderma who has
delayed gastric emptying
syndrome
c. In a patient with unexplained obstructive symptoms and history of previous abdominal surgical procedures
d. In the evaluation of a patient with severe upper gastrointestinal tract symptoms when all other tests are entirely normal
e. In the evaluation of a patient with amyloidosis who has delayed gastric emptying
20. All the following statements about octreotide are true except: a. Octreotide is the treatment of choice for severe dumping
syndrome refractory to diet b. The most common side effect of octreotide is consti-
pation c. Octreotide induces phase III activity of the migrating
motor complex d. Chronic use of octreotide is associated with the devel-
opment of cholelithiasis e. Octreotide reduces portal pressure in patients with
cirrhosis
21. A 52-year-old man who takes warfarin (Coumadin) and has an international normalized ratio (INR) of 2.3 presents with hematemesis and orthostasis. His INR is corrected with fresh frozen plasma to 1.2. He undergoes upper endoscopy after volume resuscitation within 8 hours after his original presentation. A 2-cm gastric ulcer was seen, with a nonbleeding, 1-mm, visible vessel on the greater curvature of the stomach in the antrum, and was treated with epinephrine injection and heater-probe therapy. The patient is prescribed an oral proton pump inhibitor twice daily. The patient’s hemoglobin values are listed below:
On day 2, he passes two formed black stools; on day 3, he passes one formed black stool. His vital signs are stable. Appropriate treatment on day 3 would be: a. Advance diet and observe b. Repeat esophagogastroduodenoscopy c. Infuse two more units of fresh frozen plasma d. Infuse two more units of fresh frozen plasma and repeat
upper endoscopy
Day Hemoglobin, g/dL INR
Admission 14.2 2.3 1 10.2 1.6 2 9.4 2.0 3 8.6 1.9
22. associated with orthostasis over a 5-day period. She has three alcoholic drinks per day and uses ibuprofen daily. She had two upper endoscopy studies that were normal; both were performed about 5 hours after each episode. The most likely diagnosis is: a. Gastric varices b. Gastric Dieulafoy’s lesion c. Gastric vascular ectasia d. Nonsteroidal anti-inflammatory drug (NSAID) gastric
ulcer
23. A 62-year-old man with diabetes mellitus and chronic obstructive pulmonary disease has an upper gastrointestinal tract hemorrhage requiring two units of packed red blood cells transfused for a 1-cm posterior duodenal ulcer that did not require endoscopic therapy. He was CLO (Campylobacter-like organism) test-negative and negative for H. pylori antibody. He takes no nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin and does not smoke. You see him in the clinic 5 days after discharge. The most appropriate treatment would be: a. Proton pump inhibitor twice daily for 8 weeks b. Proton pump inhibitor once a day for life c. Proton pump inhibitor once a day for 4 weeks d. Proton pump inhibitor once a day for 4 weeks with
amoxicillin 1 g twice daily and clarithromycin 1 g twice daily for 2 weeks
24. A 28-year-old woman presents with necrotizing gallstone pancreatitis. She undergoes endoscopic sphincterotomy
one 8-cm intrapancreatic collections of fluid develop and are seen with computed tomography on day 10. On day 13, hematochezia and orthostasis develop, and she receives four units of packed erythrocytes. Upper endoscopy shows a maroon clot in the distal duodenum without evidence of active bleeding. The clot was washed, showing no evident underlying abnormality and no active bleeding. The ampulla seen with the side-viewing scope showed only a sphincterotomy site. The patient was hemodynamically stable for 12 hours and then tachycardia and hematochezia developed. The most likely successful therapeutic option would be: a. Esophagogastroduodenoscopy and epinephrine injec-
tion of the sphincterotomy site b. Diagnostic laparotomy c. Angiographic embolization d. Octreotide (Sandostatin) infusion
25. A 70-year-old woman presents with a 6-hour history of left-sided crampy abdominal pain. She passed several loose, watery stools and then three maroon stools. Her blood pressure is 130/70 mm Hg, pulse 92 without orthostatic change. Physical examination shows abdomen is soft, with moderate left-sided abdominal tenderness with some localized left-sided rebound tenderness. Hemoglobin is 12.8 g/dL. Leukocyte count is 13.4 × 109/L. The most likely diagnosis is: a. Diverticular hemorrhage b. E. coli O157:H7 colitis c. Colonic vascular ectasia d. Ischemic colitis
1. Answer c The primary reason to eradicate H. pylori infection in this
patient is the need to heal the present duodenal ulcer and decrease the risk of recurrent ulceration in the future. Although 85% of gastric cancers are associated with H. pylori, the incidence of gastric cancer in the United States is 0.5%. Also, MALTomas are associated with H. pylori in 72% to 80% of patients with this tumor, but the risk of that lesion is certainly small and not inevitable. Infection with H. pylori occurs worldwide, and the overall prevalence of infection is strongly correlated with socioeconomic conditions. The prevalence among middle-aged adults is more than 80% in many developing countries such as Mexico. The infection is acquired by oral ingestion of the bacterium and is mainly transmitted within families during early childhood.
